Aetna (Essentials, Plus, Premier Plans)
Aetna Website
Exception/Prior Authorization Form
Aetna Formulary Search Tool
Directions:
Step 1: Click on Medicare Plans
Step 2: Choose Three Tier Open Formulary
Step 3: Click on “Medicare Medication Search”
Step 4: Begin Searching by Drug or Therapeutic Class
Prior Authorization Line: 1-800-414-2386
Customer Service: 1-800-529-5586
Members: 1-877-238-6211
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Anthem (Blue Standard, Blue Premier, Blue Plus Plans)
Anthem Website
To access Prior Authorization forms:
Go here, then follow these steps:
Click providers
Click physician PAB forms
Login as (caps sensitive) User: ANTHEM2 Password: ANTHEM3
Click Clinical Services
Click Reports and Publications
Click Med D Prior Auth Benefit Forms
Formulary Search Tool
Prior Authorization forms are available by contacting
Anthem directly at 1-800-338-6180
Customer Service Line: 1-866-244-1241
Member Services: 1-866-755-2776
Prior
Authorization Line: 1-800-338-6180
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CaremarkRx: Silverscript (Value, Plus, Complete Plans)
SilverScript Website
Silverscript Formulary
Click on "Abridged Formulary" (for .pdf listing) or "Formulary Search" (to search for covered drugs)
Coverage
Determination Form
Exceptions and Prior Authorizations: 1-800-294-5979
Exceptions Fax: 1-866-884-9475
Customer Service: 1-866-552-6106
Members: 1-866-235-5660
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Cigna (Cigna Plan 1, Cigna Plan 2, Cigna Plan 3)
Cigna Website
Cigna Formulary Search Tool (For .pdf versions of Plan One and Plan Two, follow links.)
Standard Forms
Coverage Determination Form
Prior Authorization: 1-800-558-9363
Customer Service: 1-800-735-1459
Members: 1-800-222-6700
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Coventry Advantra Rx (Value, Premier, Premier Plus Plans)
Coventry Advantra Website
Formulary Search Tool
Prior Authorization Form
Drug Specific Prior Authorization Forms
Quantity Limit Exception Form Link
Prior Authorization Line: (800) 551-2694
Prior Authorization Fax: 1-800-639-9158
Customer Service Line: 1-800-882-3822
Appeals and Grievance Line: 1-800-536-6167
Appeals and Grievance Fax: 1-800-535-4047
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EnvisionRx Plus (Silver, Gold Plans)
EnvisionRx Plus website
Prior
Authorization Form
Prior
Authorization Drug Specific Forms, Appeals and Grievance Information
Silver
Plan Formulary Link
Gold
Plan Formulary Link
Prior
Authorization, Quantity Limit and Step Therapy Information, Formulary Information
Member Services: 1-866-250-2005
Exceptions, Appeals and Grievance Fax:
1-866-250-5178
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First Health (Premier, Secure Plans)
First Health Premier Website
Providers Website
2009
Premier Comprehensive Formulary(.pdf)
Formulary Search Tool
Forms:
Standard Form
Coverage Determination, Prior Authorization, Appeals and Grievance Procedures Forms
Prior Authorizations (Urgent Requests Only): 1-800-551-2694
Exceptions / Prior Authorizations Fax: 1-800-639-9158
Customer Service: 1-800-588-3322
Members: 1-866-865-0662
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Health Net
Health Net
Website
Drugs
requiring PA
Comprehensive Formulary (.pdf)
Prior Authorization Form
Prior Authorization Line: 1-800-867-6564
Prior Authorization Fax: 1-800-977-8226
Customer Service/Members: 1-800-606-3604 or 1-800-949-0166
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HealthSpring
HealthSpring Website
Formulary Page
Prior Authorization form
Prior Authorization Line: 1-800-331-6293
Prior Authorization Fax: 1-866-845-7267
Customer Service Line: 1-888-299-3582
Members Line: 1-800-331-6293
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Humana (Value, Standard, Enhanced Plans)
Humana Website
Humana
Formulary Search Tool
Forms:
Prior Authorization Form
Prior Authorization Line: 1-800-555-2546
Prior Authorization Fax: 1-877-486-2621
Customer Service: 1-800-706-0872
Members: 1-800-281-6918
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Medco
Medco Website
Exceptions Request form
Formulary Search Tool
Prior Authorization Line: 1-800-935-6103
Customer Service/Members: 1-800-758-4531
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RxAmerica (Freedom, Star Plans)
RxAmerica Website
Comprehensive Star Plan Formulary (.pdf)
Standard Forms
Exceptions / Prior Authorization Line: 1-866-549-0991
Exceptions/Prior Authorization Fax: 1-866-855-2676
Customer Service: 1-877-279-0370
Members: 1-800-429-6686
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Sterling
Website
Link Including All Links
2010
Comprehensive Formulary
Prior
Authorization Criteria Link
Prior Authorization Line: 1-800-417-8164
Customer
Service Line: 1-888-858-8551
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United American: UA (UA Part D, UA Silver Plans)
Website Link
Formulary, Search Tool,
Prior Authorization, Quantity Limit and Step Therapy Guideline Link
Customer
Service for “UA Part D Plan”: 1-866-524-4169
Customer Service for
“UA Silver Plan”: 1-866-299-3406
Pharmacy/Prior Authorization Line:
1 800 753-2851
Prior Authorization Fax: 1 800 711-5673
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United Healthcare: AARP (Saver, Preferred Plans)
AARP Medicare Rx Plan Website
Search Tool:
In order to access drug search tool, please go to website, click “Look-up Prescription
Drugs” and follow instructions.
Comprehensive Formularies (.pdf files):
Preferred Plan
Saver Plan
Medication Prior Authorization Request Form
Prior Authorization Phone: 1-800-711-4555
Prior Authorization Fax: 1-800-527-0531
Customer Service: 1-866-255-4835
Members: 1-888-865-5575
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Universal American: Community CCRx (Basic, Choice, Gold Plans)
Community CCRx Website
Physician/Pharmacy Support Line: 1-866-684-5395 or TTY/TDD 1-866-684-5351 (Mon. – Sat. 7:00am to 10:30pm ET)
Formulary Search Tool
Link to Comprehensive Formulary and Addenda
Forms can be found by looking up the coverage of specific drugs under the search tool, by contacting
Legal Services for the Elderly 1-877-774-7772, or by calling the Community Care Rx Prior Authorization Line (below)
Exceptions/Prior Authorization Line : 1-866-316-6049
Appeals and Exceptions Fax: 1-866-868-0858
Customer Service/Members: 1-866-684-5353
(TTY/TTD) 1-866-864-5351
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Universal American: PrescribaRx (Bronze, Gold Plans)
Website Link
Drug
Search Tool
Comprehensive
Formulary Link
Exception
Forms
Prior Authorization Line: 1-866-316-6049
Prior Authorization
Fax: 1-866-868-0858
Customer Service: 1-877-545-6147
Member Services: 1-800-818-0007
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WellCare (Signature, Classic Plans)
WellCare Website
Physician/Pharmacist Number: 1-866-800-6111 option 2, TTY/TDD 1-888-816-5252,
Monday through Friday 7:00 a.m. to 10:30 p.m. EST
WellCare Formulary Search Tool
Signature
and Classic Plan Comprehensive Formulary Link
Coverage Determination
Form
Appeals Fax: 1-866-388-1766
Exceptions Fax: 1-866-388-1767
Phone Number for Expedited Appeals and Exceptions: 1-888-547-5252
Customer Service/Members: 1-888-547-5252
(TTY/TTD) 1-888-816-5252
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MaineCare Member Services: 1-800-977-6740
The MaineCare site has MaineCare/DEL
Formularies and Prior Authorization Forms (not Medicare Part D).
The CMS website has a
standard form for coverage determinations under Medicare Part D, together with
instructions for completing the form.
